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Former CEO of the University of Maryland Medical Center, author of the books shown above, former senior investigator at the National Cancer Institute; former head of infectious diseases and director of the University of Maryland Greenabaum Cancer Center, Professor of Medicine and Public Policy at the University of Maryland, former chair Board of Governors of NIH Clinical Center, -- along with a life long love of nature and a frequent visitor to Canaan Valley in West Virginia with my wife of 53 years.

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Tuesday, June 30, 2015

Saving Relationship Medicine with Direct Primary Care

The fundamental problem in health care delivery today is a
highly dysfunctional payment system that leads to higher costs, lesser quality
and reduced satisfaction. It also means less time between doctor and patient
with the loss of “relationship medicine.” The core problem? Price controls and
regulations that reduce the trust and core interactions between doctor and
patient. The patient is no one’s customer and visit times are all too short. I
have argued in the Washington Times as an Op-Ed that paying the doctor directly is
better for all concerned.

I believe that some of the best attempts to improve this
dysfunctional delivery system have been accomplished by primary care physicians
themselves.They have essentially said “I
won’t take it any longer; this is not good for my patients or for me.” They
have also said that it is time to “stop tinkering” and make a fundamental
change. They have opted for a new, better system – direct primary care - rather
than wait for others to fix it for them.

The concept with direct
primary care is to reduce the number of patients in a PCPs practice so that
each patient gets added time as needed. Often this means removing the insurance
system as the payer from primary care and always it means a payment model that
compensates the PCP directly by the patient. Direct primary care takes many
forms. There are two principle payment systems. One is for the patient to pay
the doctor directly
for each visit, usually at a rate far below what would have been charged in the
insurance model since the overheads of billing and coding have been eliminated.
Many such PCPs post a defined price list – transparency. This is sometimes
called direct pay or “pay at the door,” not unlike the way it was until a few
decades ago before insurance morphed from being only for major medical or
catastrophic issues to being essentially prepaid medical care.

The second model is for the patient to purchase a package of
care for the year paid by the month or annually. This basic model comes with
many variations and may be called membership,
retainer or concierge. Despite the various names, they all have certain
characteristics in common but there are many variations in how the practice
functions.

All of these models offer a reduced patient to doctor ratio:
instead of the typical 2500-3000+ patient panels, the PCP may adjust the number
of patients to a low of 300 when the panel is very ill or to a high of about 800
for a panel that has mostly low risk patients. Some accept insurance and also charge
the retainer; others just charge the monthly or annual fee.

With a reduced patient panel size, the PCP commits to
offering same or next day appointments lasting as long as necessary, a comprehensive
annual examination, email communications, and an invitation to contact the PCP
on his or her personal cell phone 24/7. Some make house calls and nursing home
visits for no extra charge; others add a modest fee. Some see their patients in
the ER and some follow their patients in the hospital.

There may be an arrangement to obtain laboratory testing,
imaging and procedures at highly discounted rates from selected vendors. Some
practices offer a limited number of laboratory tests at no charge. Some PCPs
are supplying medications at no or wholesale costs. For the patient on multiple
prescription medications, the savings on drugs can more than offset the monthly/annual
subscription cost of direct primary care.

Many only work with specialists who are willing to discount
their fees for those of their patients who pay cash and have high deductible
plans or no insurance at all.

Often regarded as highly expensive and only for the “elite,”
the rich, or the “one percent,” in fact membership/retainer/concierge practices
can be of quite reasonable cost and very appropriate for those with no or
limited insurance and for those with modest incomes – “blue collar” concierge medicine.

Fees range from about $500 to $2000 or more per person per
year. [I will ignore those doctors who charge a very high fee for “exclusive”
services.] By some degree of common usage those on the lower price end often refer
to their practices as direct primary care or membership whereas those at the
higher end often refer to their practices as retainer or concierge. To the
extent that there is any real difference, it is probably in the number of
patients in the panel or seen per day, the extent of the annual evaluation and
added values such as following one’s patients in the hospital and in the ER.

For those who have high deductible
insurance policies from work or from the exchanges, connecting with a direct primary
care physician can offer a significant savings. The individual and the
physician now have a direct professional business relationship. The person
begins to take a much more active role in the entire care process. And the
doctor can allot meaningful time for patient interaction – a return to
“relationship medicine.”

With little to
hope that government or insurers will improve the lot of primary care
physicians, direct primary care is a rational manner for PCPs to change the
paradigm and return to relationship medicine. It means better medical care,
less frustration and more satisfaction for doctor and patient alike and an
encouragement to medical students to consider primary care as a career option. It
also means that total medical care costs go down. A triple win.

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